Recurring concern
Failure to carry out required neurological observations
- Reports that mention this concern
- 26
- Times this concern has been raised
- 33
- Stated actions linked to this concern
- 55
What this concern includes
Includes failures of the neurological-observation process, including dedicated planning, continuity, staff competence, performance, accuracy, recording and adherence to applicable guidance where these failures concern neurological observations.
What is not included
- Excludes generic clinical or vital-sign observations that are not specifically neurological observations.
- Excludes generic training, staffing, documentation or monitoring deficiencies unless the report directly ties them to the neurological-observation process.
- Excludes failures of escalation or treatment that are not part of carrying out or interpreting required neurological observations.
- Excludes unrelated observation processes, including psychiatric, prisoner, postoperative or neonatal observations, unless neurological observations are explicitly involved.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 26 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to carry out neurological observations at the required frequency
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Swansea Bay University Local Health Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Swansea Bay University Local Health Board
Remind staff to follow ABMU neurological observation guidelines and disseminate the guidance through nursing leadership and professional forums.
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Swansea Bay University Local Health Board
Audit October AMU fall-patient documentation for compliance with neurological observation requirements and identify improvement and support needs.
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Concerns raised2
Failure to complete required neurological or general observations
Failure to accurately record and calculate neurological or general observations
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to conduct scheduled neuro observations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised3
Failure to carry out regular and timely neurological observations
Failure to follow hospital protocol for neurological observation frequency
Failure of nursing staff to carry out accurate neurological observations
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Deliver Trust-wide neurological-observation training for registered nurses, including competence testing.
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Concerns raised1
Insufficient post-fall neurological observations before discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sandwell and West Birmingham Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Sandwell and West Birmingham Hospitals NHS Trust
Reinforce the head-injury and falls-management pathway through face-to-face staff training.
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Sandwell and West Birmingham Hospitals NHS Trust
Issue an internal Patient Safety Notice on neurological observations and linking inpatient falls with head-injury management.
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Sandwell and West Birmingham Hospitals NHS Trust
Amend the inpatient falls policy to require post-incident monitoring and link emergency-department and ward standards.
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Sandwell and West Birmingham Hospitals NHS Trust
Install the new electronic patient record to provide decision support and alerts reinforcing inpatient-falls and head-injury standards.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Sandwell and West Birmingham Hospitals NHS Trust
Existing head-injury and inpatient-falls policies meet NICE and NPSA standards and remain suitable for staff use.
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Concerns raised2
Failure to ensure trained staff carry out neuro observations in line with policy
Failure of qualified nurse oversight to identify omitted neuro observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cardiff & Vale University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Cardiff & Vale University LHB
Assign responsibility for neurological observations to registered nurses only.
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Cardiff & Vale University LHB
Review Health Care Support Workers’ clinical skills, including their role in neurological observations.
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Concerns raised1
Failure to conduct required neurological observations after falls
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to complete or retain neurological observation charts
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Tameside and Glossop Integrated Care NHS Foundation Trust
Reissue the neurological-observations flowchart and direct ward leaders to apply its recording requirements after relevant unwitnessed falls.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Tameside and Glossop Integrated Care NHS Foundation Trust
There is no evidence that neurological observation charts were lost from the records; that inference would be conjecture.
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Concerns raised1
Failure to undertake nursing observations in accordance with required procedures and guidance
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cardiff & Vale University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Cardiff & Vale University LHB
Disseminate head-injury NICE guidance to ward sisters across the Medicine Clinical Board.
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Cardiff & Vale University LHB
Audit known fallers with head injuries for compliance with NICE guidance and UHB falls-management policies.
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Concerns raised1
Failure to institute neurological observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Stockport NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Stockport NHS Foundation Trust
Disseminate learning about vital information handover and neurological observations through meetings, safety huddles and the ED Quality Newsletter.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026